Transcript What is Patient Centered Medical Home (PCMH)?

Parkview Medical Group
Presents
KNOW Heart Disease
June 3, 2014
Inefficiencies in Healthcare
• Patient’s care is often very fragmented, involving many
specialists and/or agencies working independently of each
other.
• Poor clinical outcomes can be due to noncompliance to care.
• Patients utilize high cost facilities for care due to poor access
to their primary care provider.
• Duplication in imaging and laboratory testing often occur
leading to wasted resources and increased cost.
• Testing and Referrals tracking often are lacking, resulting in
delayed diagnosis and increased burden of illness and cost.
• Costs are escalating and are unsustainable.
PCMH is a model of care delivery for
primary care practices focused on
organizing evidence-based care around
patients, working in teams, and
coordinating and tracking care over
time.
Elements of PCMH
• Comprehensive Care
- Providing Wellness, Acute, and Chronic Care
• Patient-Centered
- Care is relationship-based; patient is a valued team member
• Coordinated Care
- Care is tracked across the entire health care system
• Accessible Services
- Increased access to care; 24/7 access to care team
• Quality and Safety
- Using evidence-based medicine; focused on performance
measurement and improvement
PCMH – Care Model
Patient
Primary Care
Provider
Care Coordinator
Seeing PCMH in Practice…
• Having same day appointments for urgent/acute issues.
• ER having access to patient’s chart after hours via on-call provider.
• Proactively reaching out to patients who are overdue for their
Wellness/Chronic Disease care.
• Giving ‘care plans’ to certain patient populations; having care
coordination for complex and noncompliant patients.
• Proactively calling patients who have been recently discharged from
the hospital.
• Calling patients who have not completed their testing and/or
referrals to improve their compliance to care.
• Reviewing medications, inquiring about recent specialist visits, and
giving visit summaries at every visit.
• Measuring clinical performance and patient satisfaction.